Monday, December 20, 2010

Good on ya, Republicans...

It would only be fair to admit I am pleasantly surprised by the Republican leadership and the actions of individual members to actually try to do something rather than just prevent action. First the tax bill, which although claiming that Obama "caved" still required considerable courage for members facing reelection challenges to support.  I mean Rush, et. al. hated it.

And now Paul Ryan, a leading figure on fiscal sanity, has teamed with Alice Rivlin to actually flesh out some details about his previously vague ideas to reform Medicare.

And I think I have seen this somewhere before...

If you're looking for a description of the Ryan/Rivlin Medicare reforms that have gained so many admirers on the right, Matt Yglesias has a good write-up of the idea. But I'd add another way of explaining the proposal: The Ryan-Rivlin plan basically turns Medicare into Obamacare. And in that context, Republicans love the idea behind ObamaCare and think it'll save lots of money.
Under the Ryan-Rivlin plan, the current Medicare program is completely dissolved and replaced by a new Medicare program that "would provide a payment – based on what the average annual per-capita expenditure is in 2021 – to purchase health insurance." You'd get the health insurance from a "Medicare Exchange", and "health plans which choose to participate in the Medicare Exchange must agree to offer insurance to all Medicare beneficiaries, thereby preventing cherry picking and ensuring that Medicare’s sickest and highest cost beneficiaries receive coverage."
Sound familiar?  [More]
In getting down to real numbers, Ryan may be discovering what Obama did about what is possible, rather than just broadcast sweeping idealistic goals. And one thing that is looking more and more useful, even as it faces judicial challenges, is requiring universal coverage.  Consider what is happening with "Romneycare".
So rather than sit around and wonder about a world without an individual mandate, let's talk about a world that has one. We don't have to go into hypotheticals to get there. We just have to go to Massachusetts.
In 2006, then-governor Mitt Romney signed a major health-care reform bill into law. "An achievement like this comes around once in a generation," he said. "Today, Massachusetts is leading the way with health insurance for everyone, without a government takeover and without raising taxes."
Given that the plan was enacted anyway, it's time to check in on how Massachusetts is doing. And the answer, basically, is pretty well. This week, the state's health and human services agency released the results of a new, independent survey examining coverage in Massachusetts. More than 98 percent - 98 percent! - of the state's residents now have health insurance, as do more than 99 percent of the state's children.
Remarkably, those numbers have gotten better in recent years, with the number of uninsured residents in the state falling to 1.9 percent in 2010 from 2.6 percent in 2008. That's very unusual. Normally, the ranks of the uninsured swell during recessions as people lose their jobs and states cut back on public programs to balance their budgets. Nationally, the number of Americans who are uninsured rose to 16.76 percent in 2010 from 14.8 percent in 2008, according to Gallup.
That Massachusetts's reforms have survived, and even prospered, in this economic environment has left the law's architects feeling vindicated. "The goal of the law was covering people," says Jonathan Gruber, an MIT health economist who worked on the legislation, "and it couldn't have gone better."[More]
Even if the courts rule the mandate unconstitutional, I have a hard time seeing legislators snatch long-awaited coverage access from children in college (or unemployed) now covered by parents, or the growing number of recission victims, or folks whose state program for high-risk are full. Those numbers are expanding, and without requiring coverage, insurers will be pounding on Congress for relief.

Besides there are other ways than the mandate to "encourage" getting coverage. Here are just three that I find acceptable.
5. Temporary higher deductibles for late sign ups – If an individual signs up for insurance after previously being uninsured, the company could be given the right to charge them a dramatically higher deductible for the first five months they are insured. This also helps eliminate the finical incentive to wait to get insurance until you get sick.
6. Multi-year waiver – This is an idea put forward by Paul Starr that should eliminate Hudson’s constitutional objections. If the individual doesn’t want to pay the mandate penalty, they wouldn’t be forced to as long as they sign away their right to guaranteed issue, community ratings, and subsidies for a set period of time, like five years. After that time, the individual can get the regulatory benefits or choose to sign another multi-year waiver.
7. Open enrollment period – You can have one month open enrollment period each year. People who sign up that month get the basic rate. The insurance companies would be allowed to charge a set higher premium for people who sign up at any other point for the rest of that year.  [More]
I suspect that while repeal will be at least attempted even Republicans are counting on the Senate to stop it. The real work will be folks like Ryan and Rivlin who will smash this vehicle into shape.

In fact, along with the economy picking up steam, and the admittedly mild effects of the limited stimulus in the tax bill, our despised Congress may prove to be more productive and effective than either side expects viewed in hindsight, at least.

We can say it is because the problems are now unavoidable, but I prefer to believe we still have folks with some spark of public service in most of the seats.

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